British Journal of Sports Medicine

British Journal of Sports Medicine

Correction: Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence

03-10-2019 –

Freke M, Kemp JL, Svege I, et al. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. Br J Sports Med 2016;50:1180. doi:10.1136/bjsports-2016-096152Due to a formula error, the authors have re-run the correct confidence in intervals with the following changes noted: all figures re-drawn; all tables amended; reflection of corrections shown in the text. The corrections are now showing online.

Making sport and sports medicine history–Lillehammer 1994, 2019 and 2021

03-10-2019 – Berge, H. M.

Welcome to this scintillating Norwegian issue of the BJSM. The Scandinavian knee ligament registries (See page 1259) were established 15 years ago, and they now inform us with data from >70 000 patients. Did you know that you can lower the risk of revision anterior cruciate ligament (ACL) reconstruction for hamstring versus patella tendon autograft by 14% for every 0.5 mm increase in hamstring graft diameter?1 In a cohort of professional male Norwegian football players followed up after 8 years (See page 1279), we found that 6 of the 595 players with negative preparticipation cardiac screening suffered a severe cardiovascular event; three of these six events were sudden cardiac arrests (SCA). Rather than introducing more preparticipation cardiac screening in Norway, we will focus on recognising athletes with early symptoms of cardiac disease. We will examine them thoroughly, and be prepared to treat SCA by having staff…

15 years of the Scandinavian knee ligament registries: lessons, limitations and likely prospects

03-10-2019 – Hamrin Senorski, E., Svantesson, E., Engebretsen, L., Lind, M., Forssblad, M., Karlsson, J., Samuelsson, K.


High-quality national health registries provide the opportunities to: (1) improve patient outcomes by giving medical units and clinicians relevant feedback about their work; (2) detect inferior treatments and (3) identify prognostic factors associated with both good and bad outcomes. The Scandinavian knee ligament registries were established in 2004 and 2005, include data from 70 000 patients,1 and have led to more than 70 studies publications already (2019). This editorial reflects on lessons learnt, limitations identified and what the future may hold. Lessons learnt Two systematic reviews including all studies from the registries focused on factors associated with (1) additional anterior cruciate ligament (ACL) reconstruction and (2) patient-reported outcomes after ACL injury and reconstruction are summarised in table 1.2 3 There is a balance in health registry studies between the large number of patients that decrease the type-II error (false negative)…

Mass media campaigns are needed to counter misconceptions about back pain and promote higher value care

03-10-2019 – OKeeffe, M., Maher, C. G., Stanton, T. R., OConnell, N. E., Deshpande, S., Gross, D. P., OSullivan, K.

Back pain is saddled by misconceptions that contribute to low-value care and poor outcomes. Many patients and clinicians mistakenly view the spine as fragile, believe that pain equates to damage and overemphasise the role and value of rest, imaging, medication and surgery.1 Guideline-based care will not be embraced if such misconceptions are not countered. Here, we provide four arguments for accessible, engaging and convincing education to the public and health professionals. Mass media campaigns can work The ‘Back Pain: Don’t Take it Lying Down’ media campaign in Victoria, Australia, aired in the late 1990s and aimed to shift public attitudes about what to do when you experience back pain.2 Television (TV) advertisements were aired for the first 12 months and again for the final 3 months of the 3-year period. There were substantial improvements in workers’ compensation costs (15% reduction in the number of claims), as well…

Woodpeckers dont play football: implications for novel brain protection devices using mild jugular compression

03-10-2019 – Smoliga, J. M., Wang, L.

As sports concussions and chronic traumatic encephalopathy have captured the media’s attention, sports organisations and athletes have become increasingly interested in novel approaches to reduce brain injury risk. One proposal is to protect the brain from within by decreasing brain ‘slosh’. This can supposedly be achieved by creating a ‘tighter fit’ of the brain within the skull.1 Woodpeckers are often cited as model organisms for achieving this,1 and one emerging device claims to replicate the woodpecker’s mechanism for protecting its brain.2 This device is a collar worn around the neck which compresses the jugular veins, known as the Q-collar or  Neuroshield ( and Unfortunately, this woodpecker-inspired concept is misguided for numerous reasons (see online for additional references).
Woodpeckers have multiple evolutionary adaptations to protect their brains. Computed tomography has confirmed that woodpeckers have numerous microstructural adaptations within the skull, including regionally specific alterations…

International consensus definitions of video signs of concussion in professional sports

03-10-2019 – Davis, G. A., Makdissi, M., Bloomfield, P., Clifton, P., Echemendia, R. J., Falvey, E. C., Fuller, G. W., Green, G., Harcourt, P., Hill, T., McGuirk, N., Meeuwisse, W., Orchard, J., Raftery, M., Sills, A. K., Solomon, G. S., Valadka, A., McCrory, P.

Journal Article

The use of video to assist professional sporting bodies with the diagnosis of sport-related concussion (SRC) has been well established; however, there has been little consistency across sporting codes with regards to which video signs should be used, and the definitions of each of these signs.
The aims of this study were to develop a consensus for the video signs considered to be most useful in the identification of a possible SRC and to develop a consensus definition for each of these video signs across the sporting codes.
A brief questionnaire was used to assess which video signs were considered to be most useful in the identification of a possible concussion. Consensus was defined as >90% agreement by respondents. Existing definitions of these video signs from individual sports were collated, and individual components of the definitions were assessed and ranked. A modified Delphi approach was then used to create a consensus definition for each of the video signs.
Respondents representing seven sporting bodies (Australian Football League, Cricket Australia, Major League Baseball, NFL, NHL, National Rugby League, World Rugby) reached consensus on eight video signs of concussion. Thirteen representatives from the seven professional sports ranked the definition components. Consolidation and refinement of the video signs and their definitions resulted in consensus definitions for six video signs of possible concussion: lying motionless, motor incoordination, impact seizure, tonic posturing, no protective action—floppy and blank/vacant look.
These video signs and definitions have reached international consensus, are indicated for use by professional sporting bodies and will form the basis for further collaborative research.

Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis

03-10-2019 – Culvenor, A. G., Oiestad, B. E., Hart, H. F., Stefanik, J. J., Guermazi, A., Crossley, K. M.

Knee MRI is increasingly used to inform clinical management. Features associated with osteoarthritis are often present in asymptomatic uninjured knees; however, the estimated prevalence varies substantially between studies. We performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees.
We searched six electronic databases for studies reporting MRI osteoarthritis feature prevalence (ie, cartilage defects, meniscal tears, bone marrow lesions and osteophytes) in asymptomatic uninjured knees. Summary estimates were calculated using random-effects meta-analysis (and stratified by mean age: <40 vs ≥40 years). Meta-regression explored heterogeneity.
We included 63 studies (5397 knees of 4751 adults). The overall pooled prevalence of cartilage defects was 24% (95% CI 15% to 34%) and meniscal tears was 10% (7% to 13%), with significantly higher prevalence with age: cartilage defect <40 years 11% (6%to 17%) and ≥40 years 43% (29% to 57%); meniscal tear <40 years 4% (2% to 7%) and ≥40 years 19% (13% to 26%). The overall pooled estimate of bone marrow lesions and osteophytes was 18% (12% to 24%) and 25% (14% to 38%), respectively, with prevalence of osteophytes (but not bone marrow lesions) increasing with age. Significant associations were found between prevalence estimates and MRI sequences used, physical activity, radiographic osteoarthritis and risk of bias.
Summary estimates of MRI osteoarthritis feature prevalence among asymptomatic uninjured knees were 4%–14% in adults aged <40 years to 19%–43% in adults ≥40 years. These imaging findings should be interpreted in the context of clinical presentations and considered in clinical decision-making.

Cardiovascular incidents in male professional football players with negative preparticipation cardiac screening results: an 8-year follow-up

03-10-2019 – Berge, H. M., Andersen, T. E., Bahr, R.

Preparticipation cardiac screening of athletes aims to detect cardiovascular disease at an early stage to prevent sudden cardiac arrests and deaths. Few studies have described the cardiovascular outcomes in athletes classified as negative on screening.
To identify cardiovascular incidents in a cohort of male professional football players who were cleared to play after a negative screening result.
This is a retrospective 8-year follow-up study of 595 professional male football players in Norway who underwent preparticipation cardiac screening by experienced cardiologists, including electrocardiography (ECG) and echocardiography, in 2008. We performed a media search to identify sudden cardiovascular incidents between January 2008 and February 2016. Incidents were cross-checked with medical records.
Six of the 595 players (1%), all classified as negative on cardiac screening, experienced severe cardiovascular incidents during follow-up. Retrospective review revealed abnormal ECG findings in one case, not recognised at the time of screening. Three players suffered a sudden cardiac arrest (all resuscitated successfully), one a myocardial infarction, one a transient ischaemic attack and one atrial flutter. Three of the players ignored chest pain, paresis, dyspnoea or near-syncope, two completed a match with symptoms before seeking medical assistance, one player’s symptoms were misinterpreted and received inappropriate treatment initially, and two players were discharged from hospital without proper follow-up, despite having serious cardiovascular symptoms.
A comprehensive preparticipation cardiac screening did not identify a subset of 6 of 595 players who experienced subsequent cardiovascular incidents as being at risk. It is important to remind athletes that a normal cardiac screening exam does not protect against all cardiac diseases. Timely reporting of symptoms is essential.

Does MRI add value in general practice for patients with traumatic knee complaints? A 1-year randomised controlled trial

03-10-2019 – Swart, N. M., van Oudenaarde, K., Bierma-Zeinstra, S. M., Bloem, H. J., van den Hout, W. B., Algra, P. R., Bindels, P. J., Koes, B. W., Nelissen, R. G., Verhaar, J. A., Reijnierse, M., Luijsterburg, P. A.

To determine whether referral to MRI by the general practitioner (GP) is non-inferior to usual care (no access to MRI by GPs) in patients with traumatic knee complaints regarding knee-related daily function.
This was a multicentre, non-inferiority randomised controlled trial with 1-year follow-up. GPs invited eligible patients during or after their consultation. Eligible patients (18–45 years) consulted a GP with knee complaints due to a trauma during the previous 6 months. Patients allocated to the MRI group received an MRI at (median) 7 (IQR 1–33) days after the baseline questionnaire. Patients in the usual care group received information on the course of knee complaints, and a referral to a physiotherapist or orthopaedic surgeon when indicated. The primary outcome measure was knee-related daily function measured with the Lysholm scale (0 to 100; 100=excellent function) over 1 year, with a non-inferiority margin of 6 points.
A total of 356 patients were included and randomised to MRI (n=179) or usual care (n=177) from November 2012 to December 2015. MRI was non-inferior to usual care concerning knee-related daily function during 1-year follow-up, for the intention-to-treat (overall adjusted estimate: 0.33; 95% CI –1.73 to 2.39) and per-protocol (overall adjusted estimate: 0.06; 95% CI –2.08 to 2.19) analysis. There were no differences between both groups in the amount of patients visiting other healthcare providers.
MRI in general practice in patients with traumatic knee complaints was non-inferior to usual care regarding knee-related daily function during 1-year follow-up.
Trial registration number

Sudden cardiac arrest in sports: a video analysis

03-10-2019 – Steinskog, D. M., Solberg, E. E.

Information about sudden cardiac arrest (SCA) in sports arises from registries, insurance claims and various reports. Analysing video footage of SCA during sports for scientific purposes has scarcely been done. The objective of this study was to examine videotaped SCA in athletes to better understand the mechanisms of SCA.
Publicly available online video databases were searched for videos displaying SCA in athletes.
Thirty-five online videos (26 from professional and 9 from amateur sport; 34 male victims) were obtained. Twenty-one events resulted in survival and 14 in sudden cardiac death. Level of physical activity prior to SCA was assessable in 28 videos; 19 events occurred during low-intensity, 6 during moderate-intensity and 3 during high-intensity activity. SCA predominately occurred during low-intensity compared with both moderate-intensity and high-intensity activities (p<0.01). In 26/35 videos, it was possible to observe if resuscitation was provided. Resuscitation was carried out in 20 cases; cardiopulmonary resuscitation (CPR) alone (8 cases), CPR+defibrillation (10), cardiac thump (1) or shock from an implantable cardioverter defibrillator (1). Thirteen of the 20 cases with resuscitation received an intervention within 1 min after collapse. Survival was high when intervention occurred within 1 min (12/13) compared with those who received delayed (3/5) or no intervention (1/6). Associated signs of SCA such as agonal respirations and seizure-like movements were observed in 66% of the cases.
SCA during sport most often occurred during low-intensity activity. Prompt intervention within 1 min demonstrated a high survival rate and should be the standard expectation for witnessed SCA in athletes.

International study of video review of concussion in professional sports

03-10-2019 – Davis, G. A., Makdissi, M., Bloomfield, P., Clifton, P., Echemendia, R. J., Falvey, E. C., Fuller, G. W., Green, G., Harcourt, P. R., Hill, T., McGuirk, N., Meeuwisse, W., Orchard, J. W., Raftery, M., Sills, A. K., Solomon, G. S., Valadka, A., McCrory, P.

Video review has become an important tool in professional sporting codes to help sideline identification and management of players with a potential concussion.
To assess current practices related to video review of concussion in professional sports internationally, and compare protocols and diagnostic criteria used to identify and manage potential concussions.
Current concussion management guidelines from professional national and international sporting codes were reviewed. Specific criteria and definitions of video signs associated with concussion were compared between codes. Rules and regulations adopted across the codes for processes around video review were also assessed.
Six sports with specific diagnostic criteria and definitions for signs of concussion identified on video review participated in this study (Australian football, American football, world rugby, cricket, rugby league and ice hockey). Video signs common to all sports include lying motionless/loss of responsiveness and motor incoordination. The video signs considered by the majority of sports as most predictive of a diagnosis of concussion include motor incoordination, impact seizure, tonic posturing and lying motionless. Regulatory requirements, sideline availability of video, medical expertise of video reviewers and use of spotters differ across sports and geographical boundaries. By and large, these differences reflect a pragmatic approach from each sport, with limited underlying research and development of the video review process in some instances.
The use of video analysis in assisting medical staff with the diagnosis or identification of potential concussion is well established across different sports internationally. The diagnostic criteria used and the expertise of the video review personnel are not clearly established, and research efforts would benefit from a collaborative harmonisation across sporting codes.

Infographic. Thermoregulatory impairment in athletes with a spinal cord injury

03-10-2019 – Griggs, K. E., Havenith, G., Price, M. J., Goosey-Tolfrey, V. L.

Journal Article

Presented in this infographic is a summary of studies investigating the thermoregulatory impairment of athletes with a spinal cord injury (SCI) during real-world sporting scenarios.1–3 The infographic depicts the heightened thermal strain experienced by athletes with tetraplegia (high-level lesions), both compared with athletes with paraplegia (low-level lesions) and within the sport of wheelchair rugby. In addition to the cooling interventions presented, the infographic highlights the significant need for appropriate interventions to reduce the risk of overheating and potential performance decrements.4 This infographic was field tested with those who work within a wheelchair sports environment, ranging from practitioners, researchers, athletes with an SCI and sports clinicians. The experimental studies were also designed in consultation with the wheelchair rugby coaches and players. Contributors
All the authors were all involved in the design, analysis and contributed towards writing of the manuscripts of the studies highlighted in…

Infographic. Relative energy deficiency in sport: an infographic guide

03-10-2019 – Keay, N., Rankin, A.

Journal Article

Relative energy deficiency in sport (RED-S)1 is a clinical syndrome encompassing adverse health and performance (figure 1) consequences of low energy availability (LEA)2 in male3 and female exercisers of all ages and all levels from recreational to elite. LEA is a situation where energy intake is insufficient to cover the combined energy demands of training and baseline physiological processes to maintain health. LEA can arise unintentionally or intentionally (figure 2). Unintentional LEA results from increased training load, which is not matched by an increased energy intake. Intentional LEA is more likely to arise in sports where low body weight confers a performance or aesthetic advantage, for example, gravitational sports including cycling, ski-jumping, climbing; weight-category sports including boxing and judged artistic sports including gymnastics, aquatic disciplines. RED-S is also a risk in dancers of all genres, but in particular ballet.4…

Infographic. Energy availability: concept, control and consequences in relative energy deficiency in sport (RED-S)

03-10-2019 – Keay, N., Francis, G.

Journal Article

Relative energy deficiency in sport (RED-S) is an issue of increasing concern in sports and exercise medicine. RED-S impacts exercisers of all levels and ages, particularly where low body weight confers a performance or aesthetic advantage. Key to mitigating adverse health and performance consequences of RED-S is supporting athletes and dancers to change behaviours. These infographics aim to assist clinicians in communicating the concepts to exercisers and in implementing effective management of athletes in their care.1 Figure 1 illustrates the concept of energy availability (EA) in RED-S. Preferentially energy derived from dietary intake covers the demands of training, and the remaining energy, EA, is quantified in kcal/kg of fat free mass.2 In figure 1, the central bar illustrates adequate EA in an athlete where energy intake is sufficient to cover the demands of training and fundamental life processes to maintain health….

Exertional heat stress-induced gastrointestinal perturbations: prevention and management strategies

03-10-2019 – Snipe, R. M. J.

What did I do? I investigated the effects of heat stress and nutrition strategies on gastrointestinal and associated systemic disturbances during endurance running. I aimed to identify the effect of heat stress on gastrointestinal perturbations during prolonged running and subsequently explore the effectiveness of nutrition prevention strategies. Why did I do it? Gastrointestinal disturbances are common during endurance running events affecting ≥60% of athletes and may contribute to impaired nutrition intake, poor performance and withdrawal from competition.1 2 The greatest prevalence of gastrointestinal and associated systemic disturbances (eg, endotoxaemia and cytokinaemia) has been reported during endurance running (≥2 hours of running at ≥60% maximal oxygen uptake (VO2max)) events held in the heat.1 No studies had previously explored the effects of heat exposure during endurance running on gastrointestinal symptoms and/or in conjunction with gastrointestinal integrity, systemic endotoxaemia and cytokinaemia. Further, research on prevention strategies targeting the…

Preventing overdiagnosis and the harms of too much sport and exercise medicine

03-10-2019 – Friedman, D. J., Khan, K. M.

Journal Article

Do I really need this test, treatment or procedure? What are the downsides? What happens if I do nothing? And are there simpler, safer options?  These four questions, promoted by Choosing Wisely Canada, featured prominently at the two 2018 conferences, Too Much Medicine in Helsinki, Finland (figure 1), and the sixth annual Preventing Overdiagnosis conference in Copenhagen, Denmark. Over 600 of the world’s leading researchers and thinkers in preventing overdiagnosis came together for two weeks in August 2018 to highlight the problems caused by medical excess and to identify evidence-informed practices to wind back the harms of too much medicine. This education review aims to bring the sport and exercise medicine reader up to date on this topic. An expanded version with additional references and resources is provided in the online . Too many people are being overdiagnosed, leading to overtreatment and wasted resources that could be better…

Katherine Dec #SportsDoc #OutstandingSportsPerson

03-10-2019 – Ross, A., Dec

Fondest career memory? Working directly with my longtime friend, Cindy Chang, MD. We met through volleyball and in our residency training years despite an OSU and MSU rivalry. We planned to work together professionally despite jobs and families pulling us to opposite coasts. Then in 2008, with the Beijing Paralympics, we were both selected as physicians for team USA with the US Olympic Committee. All those years of practising my Mandarin made it twice as enriching. A letter to your high school self, what would it say? Dear Kathy, stop worrying about how people judge you. Realise that failure is only a means to greater success. Remember it is about the moments and the experience of living that creates a life. My extended family will tell you I still need to read these words as my perfectionist tendencies surface sometimes! Average weekday morning? Wake up before…

Getting back to football after having a total hip replacement (twice)

03-10-2019 – Sinclair, M.

Journal Article

When I was a young boy watching my Dad play football, I remember wanting to be just like him. I was delighted when I joined my first team but for one reason or another I got kicked out of the team. This might have been because of my disability—I have cerebral palsy so I’m not sure if it was because of that. I moved onto another team and never looked back from there as football is my life! I am most proud of being able to play in the Paralympics at London 2012 for the Great Britain Cerebral Palsy football team, as well as playing in several major international tournaments for the England Cerebral Palsy team. It was a great experience for me to travel around the world doing what I love. Walking out in front of 80 000 people at the opening ceremony of the London 2012 Paralympics is…

Clarifying the roles of patients in research

03-10-2019 – Liabo, K., Boddy, K., Burchmore, H., Cockcroft, E., Britten, N.

The term ‘patient’ no longer denotes a passive recipient of healthcare. Patients have demanded, and are increasingly given, the opportunity to influence health services and policies.1 Similarly, in health research patients are sought as partners in study design and governance.2 This is reflected in The BMJ’s patient partnership initiative (,3 the Patient-Centred Outcomes Research Institute (PCORI) in the US,4 and the National Institute for Health Research (NIHR) in the UK.5 Because of the history of (un)ethical conduct in research, including patients as partners in research studies requires clarity about what the role includes. Patients’ roles must be defined so that we achieve meaningful patient partnership and well conducted, ethical research. ‘The patient’ is a construct that assumes an inherent imbalance of power and includes expectations of compliance by those inhabiting it.6 That it has taken…